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Sr- roaquin County-Environmental Health Departrr--t PAYMENT 304 E Weber nue-Third Floor-Stockton CA 95202-Phoi. )9468-3420 IVED R;= ,E` APPLICATION Lt L G 2" - ENVIRONMENTAL HEALTH ' r4TY PERMIT TO OPERATE , rl JC7�nU�N .. r EMPLOYEE HOUSING OR LABOR CAMP G, NVINI".'icN li t !1i F1 DIVISION ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year 2 0 0 3 ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 0001462 Please Note any Corrections or Changes in Facility/Operator Information directly on this Camp ID#: 39/00116 Site Name: GOGNA,VERNON 39-176 Location: 13959 E FANNING RD,STOCKTON Operator: GOGNA,VERNON Mailing Address: 13959 E FANNING RD,STOCKTON CA 95215 Facility Phone#:(209)931-4392 Legal Owner: GOGNA,VERNON New Owner? ❑Yes ❑ No Owner Address: 13959 E FANNING RD,STOCKTON CA 95215 Owner Phone#:(209)931-439� Community Facilities Provided by Camp: Community Kitchen: LJYesNILJ Men: Number of Toilets Number of Showers Number of lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees from/y_/1 Rn3o-LL/j-5/o-3Crop BERRIES Dormitories from_/_/_to_/_/_Crop SF Dwellings Apartments Total Number of Days to be used this Calendar Ycar_ Owner Owned MH/RV Total Days Occupied by 25 or more Employees_ Owner Owned RR Cars Note: MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year TOTALS require a Public Water System Permit. ❑ Inactive Important: In order to protect your land use status,if camp will not be used this year but is intended for use in the future,Check this Box and return this application. Fee Schedule ❑Permanent Camp Annual Permit Fee: $35.00+ Number of Employees @ $12.00 each=$ Orchard Camp Permit Fee: $95.00=$ 95 . 00 nn Transfer of Ownership: $20.00=$ El Late Amendment Fee: $20.00+ Number of Agional Employees @ $12.00 each=$_ Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ Fee must be uQmitted with Application TOTAL,FEE DUE: $ 95 . 00 Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE CHECKS PAYABLE TO: PITS-END Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name DENNIS GOGNA Title PARTNER g®Partnership (Please PRINT or TYPE) ❑Corporation Address 13959 E. F ING ROAD STOCKTON , CA. 95215-9730 Phone (209) 93 1—2 664 Applicant Signature r+- Date of Application Aq lg� Amount Paid Date of Payment Payment Type Check/ ecelpt# Received By Account ID 167 / yq D3 61 �G�� 0001463 IFFacility ID Program Record ID PIE Assigned to PWS ID —0001464 0270176 2755 1522-VAN BUREN 0001462 Report#:7066.rpt I ., Ir I pig b4 Application Printed:11/20/2002